Knowing the terms associated with a profession is an important part of being able to work in and advance it. And credentialing, privileging, and enrollment are no exceptions. But as healthcare organizations inch toward combining or sharing resources for these functions, a terminology check is in order.
Are you using the following words to mean different things than your counterparts in credentialing (or enrollment)?
Credentialing is perhaps the most widely disparate term used in healthcare. It’s diversity knows few bounds, as people in the entire profession, in healthcare system/organizations, and even departments use it to mean different processes. These range from practitioners’ credentials verification (primary source or not), to hospital privileging, to enrolling providers with commercial or government payers. A good deal of the confusion exists for two main reasons:
- Within hospitals and other healthcare organizations that process practitioners, 1) credentialing and then privileging steps have been conducted on a parallel track with 2) enrollment for a long time, with near zero interaction of the staff or resources between them. Now the two appear to be aligning, under the directive to create efficiencies across the workflows.
- Billing companies, insurers/payers, group practices, managed care organizations, and other non-hospital healthcare entities have established terminology of their own. And since they do not credential to privilege, grew to use the term credential differently and in conjunction with their own provider verification process culminating in enrollment.
Because credentialing (which includes primary source verification) initiates the gathering of data that will be used eventually for both enrollment and clinical privilege delineation, consensus is to use the term to reference only the steps of gathering and approving/verifying practitioner data and required associated materials. It should not be used to stand in for the term primary source verification, and it should not describe steps extending into the privileging process. Finally, it should not be used as a synonym for payer/provider enrollment.
Payer vs. payor — AND — payer/payor enrollment vs. provider enrollment
There are two doozies wrapped up in this terminology, which can trip up even the most seasoned veterans.
Payor is an alternative way to spell payer, à la adviser/advisor, theater/theatre, and orthopaedic/orthopedic. Thank goodness for dictionaries and style guides. Feel free to use either spelling, but it’s best to remain consistent once your organization makes the call.
Moving onto payer enrollment vs. provider enrollment, your usage might just depend on what chair you occupy. IntelliSoft Group has customers who work for hospitals and healthcare organizations, private practices, CVOs, DSOs, insurance companies (aka payers), and more. If you service the provider and most of your interaction is with them, you might call what you do provider enrollment (but not always!)—getting the clinician (your customer) listed with the payer to be able to bill for and list them in directories. On the flip side, if you service a CVO or insurer, there’s probably a slightly higher percentage of you who call your job payer enrollment (but not always!). There are no studies or polls, so take this info as anecdotal and reach out to ISG if you have insight.
In summary, payer/payor and payer enrollment/provider enrollment mean the same thing. Both describe the steps taken after a contract is established with a commercial (private) payer or government payer (CMS) to enroll practitioners in their plans (also called panels), and to re-enroll as necessary.
Delegate, too, works double time in the credentialing, privileging, and enrollment worlds.
First use: Delegation (verb) is an optional, formal process whereby a healthcare organization’s or health plan’s department responsible for credentialing and/or enrollment agrees to turn over some function(s)—typically primary source verification—to a qualified organization. Many healthcare organizations, but typically larger ones such as hospital systems and entities under their umbrella (i.e., health plans, acute care, surgery center, critical access hospitals), delegate or outsource to a CVO that’s either internal or external/third-party. But it doesn’t have to be a CVO that takes on the work. It could be another department, or any kind of third party qualified to do the work.
Second use: You can become a delegate (noun). Qualified healthcare organizations including CVOs can achieve delegated status with payers/insurers/health plans/managed care companies. The “delegated” part of the term means the same as above, i.e., one entity turns over functions to another under a formalized contract and process. Within a delegation relationship involving a payer/insurer, that payer is relying on the other organization to do part of the work for them, again typically PSV and credentialing. Most delegated relationships are for NCQA-certified organizations enrolling +150 providers, but every payer/health plan sets its own standards for what’s acceptable. A threshold number exists because efficiency is delivered only once a certain volume is reached. If you meet those qualifications, the delegation process usually follows a few typical steps you can learn about here.
OK, are we all pulling in the same direction now?!
P.S.: In case you’re puzzled about the title of this blog, it’s a riff on the 1983 drama, Terms of Endearment, trailer here. Enjoy!